Healthcare Provider Details

I. General information

NPI: 1710957485
Provider Name (Legal Business Name): RUSSELL W BECKER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 VETERANS PARK DR STE 2203
NAPLES FL
34109-0596
US

IV. Provider business mailing address

1875 VETERANS PARK DR STE 2203
NAPLES FL
34109-0596
US

V. Phone/Fax

Practice location:
  • Phone: 239-431-5884
  • Fax: 239-631-6907
Mailing address:
  • Phone: 239-431-5884
  • Fax: 239-631-6907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberOS12827
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: